Accountability and delegation
A guide for the nursing team
The nursing team is made up of many
different people bringing with them a range
of skills, knowledge and competence.
The person in overall charge of the nursing care of
the patient is usually the registered nurse. But the
nurse cannot perform every intervention or activity
for every patient or client and therefore they will
need to delegate aspects of care to colleagues.
The principles of accountability
and delegation, explained in this
leaflet, can be applied to any
relevant member of the nursing team
including health care assistants,
assistant practitioners, registered
nurses and nursing students.
Accountability: You and the law
Health service providers are accountable to both
the criminal and civil courts to ensure that their
activities conform to legal requirements. In addition,
employees are accountable to their employer to
follow their contract of duty.
Registered practitioners are also accountable
to regulatory bodies in terms of standards of
practice and patient care (RCN et al., 2006).
The law imposes a duty of care on practitioners,
whether they are health care assistants (HCAs),
assistant practitioners (APs), students, registered
nurses, doctors or others, when it is “reasonably
foreseeable” that they might cause harm to
patients through their actions or their failure to
act (Cox, 2010).
The duty of care applies whether they are
performing straightforward activities such as
bathing patients or undertaking complex surgery.
In each instance there is an opportunity for harm to
occur. Once a duty of care applies, the key question
to ask is: what standard of care is expected of
practitioners performing particular roles?
All practitioners must ensure that they perform
competently. They must also inform a senior
member of staff when they are unable to
perform competently.
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In order for anyone to be accountable they must:
• have the ability (knowledge and skills) to perform
the activity or intervention
• accept the responsibility for doing the activity
• have the authority to perform the activity within
their role, through delegation and the policies and
protocols of the organisation.
Case study: following the process
Jo, an HCA, is working in the respiratory clinic at a
GP surgery. She performs spirometry on a patient,
having been previously assessed as competent to
carry this out following training and education in
spirometry (ability).
The role forms part of her job description
(responsibility). The respiratory nurse
has delegated this activity (authority)
to her in full knowledge of her level of
competence and job description.
The nurse retains the professional responsibility
of appropriate delegation and Jo, though not
currently regulated, is accountable for her actions.
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Delegation
Registered nurses have a duty of care and a legal
liability with regard to the patient. If they have
delegated an activity they must ensure that it has
been appropriately delegated.
The Nursing and Midwifery Council’s (NMC) code
(2015) states in the section entitled ‘Practise
effectively’ that registrants must:
Be accountable for your decisions to delegate tasks
and duties to other people
To achieve this, you must:
• only delegate tasks and duties that are within the
other person’s scope of competence, making sure
that they fully understand your instructions
• make sure that everyone you delegate tasks to
is adequately supervised and supported so they
can provide safe and compassionate care, and
• confirm that the outcome of any task you
have delegated to someone else meets the
required standard.
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Delegation of duties is summarised in this
statement from NHS Wales (NLIAH, 2010)
“Delegation is the process by which you (the
delegator) allocate clinical or non-clinical
treatment or care to a competent person (the
delegatee). You will remain responsible for the
overall management of the service user, and
accountable for your decision to delegate. You will
not be accountable for the decisions and actions of
the delegatee”.
Employers have responsibilities too,
and as HCAs and APs develop and
extend their roles the employer must
ensure that its staff are trained and
supervised properly until they can
demonstrate competence in their new
roles (Cox, 2010).
Employers accept ‘vicarious liability’ for their
employees. This means that provided that
the employee is working within their sphere
of competence and in connection with their
employment, the employer is also accountable
for their actions.
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Principles of delegation:
• Delegation must always be in the
best interest of the patient and not
performed simply in an effort to save
time or money.
• T he support worker must have been suitably
trained to perform the intervention.
• Full records of training given, including dates
should be kept.
• Evidence of competence assessment should
be recorded, preferably against recognised
standards such as National Occupational
Standards (www.skillsforhealth.org.uk).
• T here should be clear guidelines and protocols in
place so that the support worker is not required to
make a ‘stand alone’ clinical judgement.
• T he role should be within the support worker’s
job description.
• T he team and any support staff need to be
informed that the activity has been delegated
(for example, a receptionist in a GP surgery or
ward clerk in a hospital setting).
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• T he person who delegates the activity must
ensure that an appropriate level of supervision
is available and that the support worker has
the opportunity for mentorship. The level of
supervision and feedback provided must be
appropriate to the activity being delegated. This
will be based on the recorded knowledge and
competence of the support worker, the needs of
the patient/client, the service setting and the
activities assigned (RCN, 2012).
• Ongoing development to ensure that competency
is maintained is essential.
• T he whole process must be assessed
for the degree of risk.
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Case study: knowing the boundaries
An HCA in a nursing home is helping
a patient with diabetes to remove
their socks before bed and notices
that there is a wound on the patient’s
large toe which looks inflamed.
Although the HCA is experienced and competent
at standard dressings she is aware of the risks
associated with wounds on the feet of patients
with diabetes and therefore knows that to
treat this would be outside of her sphere of
competence. She is also aware that the wound
has not yet been assessed by a registered nurse.
The HCA reports the wound to the registered
nurse who takes over the care of that wound.
The HCA has acted according to the protocols of
the workplace and can justify her actions. She
has demonstrated that she understands her
accountability and responsibilities towards
that patient.
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Points to check when delegating
Best interest of patient
Education and training
Competent and written evidence of assessment
Protocols
Job description
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Is it still in the best interest of
the patient to delegate?
Risk management
Ongoing professional development
Supervision and mentorship
Everyone knows task has been delegated
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Case study: risk management
As instructed by the nurse in charge,
Gita, an HCA, is working in a bay on
a medical ward, observing a patient
with a diagnosis of depression and
unstable diabetes.
The patient expresses to Gita that he has suicidal
thoughts. Gita is aware that the patient has
previously self-harmed. She uses the patient call
bell to bring the nurse in charge
to the patient’s bedside.
She reports her conversation with the patient to
the nurse in charge so that the nurse can assess
the patient and decide on the appropriate action
and plan of care. Gita is aware that dealing with
this risk to a vulnerable patient is outside her
level of competence and that timely referral to the
registered nurse is appropriate.
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Delegation checklist
Are you delegating an activity to an HCA?
Ask yourself the following questions:
Delegation must take into account the
context of every situation rather than
focusing on activities alone.
• Is delegation in the best interests of the patient?
• Have you considered the clinical risk involved
in delegating?
• Do you have authority to delegate the work and
the appropriate clinical knowledge?
• Does the HCA have the skills and knowledge
required to undertake the activity, including
communication and interpersonal skills, as well
as clinical competence?
• Does the HCA have the capacity to take on
additional work?
• C an you provide support and supervision
and check that the outcome of the
delegation meets the required standard?
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Have you answered yes to all of these
questions?
• If so, then delegation is appropriate.
• If not, you must not delegate the activity as it
would not be appropriate or in the best interests
of the patient. If there is a need for additional
training and development, consider when and
how this need may be addressed.
Once you have determined that delegation
is appropriate, follow these steps:
1. Prepare
• Refer to or develop robust protocols and
procedures based on current best practice.
• Check the HCA job description is up to date.
2. Communicate
• Clearly explain the activity to be delegated to the
member of staff and ensure it is fully understood.
• Make sure all other members of the
team involved understand what
is to be delegated, who to, the
process involved, and their own
accountability and responsibility.
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• Check with the colleague that they
understand the required outcome of
the delegated activity and should not
attempt to perform any further duties
beyond what has been instructed.
• Ensure the person to whom you delegate is aware
of their responsibility to raise issues of concern,
report back and seek support when appropriate.
3. Training and assessment
• P rovide appropriate training,education and
assessment for the person to undertake the
delegated activity.
• F ollowing the training, ensure a competence
assessment has taken place and is documented,
building in a regular review of competence
(RCN 2012).
• Keep records and review training and
development needs regularly.
• P rovide regular supervision and monitoring.
4. Evaluate
• W hat were the benefits of delegating the activity?
• Did it go to plan, and if not, why not?
• W hat can be done to ensure any difficulties are
avoided next time?
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Are you being asked to accept the
delegated activity? Follow this checklist
to determine whether or not it’s
appropriate for you to accept it.
• Has the degree of risk been considered?
– A re you sure that the activity is not too complex
for you to accept? Would you be compromising
patient care by accepting it?
• Does the person delegating have the authority to
delegate the work?
– A re you confident that they hold the appropriate
clinical knowledge to delegate the activity to you?
• Do you have the skills and knowledge required to
undertake the task?
– A re you confident about the communication and
interpersonal skills required as well as your
clinical competence?
• A re you sure that accepting the work will not
impact on your performance?
– Do you have the capacity to take on
additional work?
Have you answered yes to all of these questions?
Then accept the delegated activity. If not, say no:
accepting it would not be appropriate and in the
best interests of the patient.
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After accepting the delegated work:
• keep your skills and knowledge up
to date. Request regular updates
with your supervisor if you are not
offered them
• work within guidelines: There must be clear and
robust protocols in place and these must be
reviewed regularly
• regularly check that your job description is
accurate and up to date, reflecting the new roles
and responsibilities
• do you know what to do if you have any concerns?
There must be adequate supervision and access
to support when required. You have a duty to let
your colleagues know and not to undertake any
activities that you do not feel is appropriate at
that time.
Delegation must be safe and aim to improve the
care of all patients within any given setting.
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If you are unsure about any aspect of delegation,
always seek further advice or clarification.
For more information and advice on the issues
within this booklet, visit www.rcn.org.uk/hca or
RCN members can call RCN Direct on 0345 772 6100
References
Cox C (2010) Legal responsibility and
accountability; Nursing management 17: 3: 18-20
June 2010
NLIAH (National Leadership and Innovations
Agency for Healthcare) (2010) All Wales guidelines
for delegation
Nursing and Midwifery Council (2015) The Code:
professional standards of practice and behaviour
for nurses and midwives www.nmc-uk.org/Therevised-Code/ (Accessed 10 March 2015.)
Royal College of Nursing et al (2006) Intercollegiate
paper: Supervision, accountability and delegation
of activities to support workers: a guide for
registered practitioners and support workers.
Royal College of Nursing (2008) Health care
assistants and assistant practitioners. Delegation
and accountability.
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Royal College of Nursing (2012) Position statement
on the education and training of HCAs.
Skills for Health (2015) (www.skillsforhealth.
org.uk/standards/item/215-nationaloccupational-standards ) (Accessed 2 March 2015)
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Pub code: 004 852
June 2015